Intestinal Rehabilitation Webinar 2023 - Top 5 Key Takeaways

Global Cast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello, everyone. In November 2023, we held the First Intestinal Rehabilitation Webinar here at Cincinnati Children's Hospital. For that, we had the experts of the Intestinal Rehabilitation Center at Cincinnati Children. Dr. Pro Wales, the current director of the Intestinal Rehabilitation Center, and Dr. Michael Heran, the prior director of the Intestinal Rehabilitation Center, and the director of the Center of Stem Cell and Organoid Medic. So, today, we are going to highlight the five main topics they talked at the one. Let's start. First, infants and babies have a great potential for intestinal growth. One key thing to to acknowledge is that young infants, babies, infants, and young children have tremendous gut growth potential. The gut grows for the first several years of life. Um, and that's why when we're we're talking about residual bowel, it's really important to talk about it, not in absolute centimeters, as I did in this case, 14 cm. It's to talk about it in relationship to what is normal for a child of that age. So, a term baby, uh, will have 160 centimeters of small bowel, and by the time you're five years old, it it almost triples, about 425 to 450 centimeters. So, talking about centimeters without the age is not appropriate because we need to know the percentage of gut that we have to know the prognostic and autonomy potential of that intestine. That's why it's really important in the context of young children. We talk about it as a percentage. So we have 10% of small bowel, 75% of colon. What you can have is low as 10% expected gut length and still achieve enteral autonomy if you have the majority of your colon and continuity. So another key factor for enteral autonomy is functionality, and to assess it, we need to know the underlying diagnosis. Remember, babies are born with their intestines capable of adapting and growing. It's not only about the length, but how we support the growth journey. Second key takeaway is the importance of the distal ilium and the function of the remaining bowel. Lots of papers will quote the importance of the ICV. What do you think about that? So, to me, I believe the more important fact is the presence or absence of the distal small bowel or the ileum or even right colon that can act as a reclamation of bile and get the enterohepatic circulation as well as producing hormones and incretins like, uh, GLP2 is in everyone's mind these days, but, you know, all the incretins GLP1 and and even hormones like PYY are produced in the distal ileum, but it's not because of the ileocecal valve, it's because of to me the ileum. So, remember, the ileocecal valve is not the main part of the intestine. What's important is the distal ileum and proximal colon, where the bilioenteric circulation is key, and what we produce hormones and peptides that help intestinal growth and intestinal absorption. Third key takeaway. It is really important to have a surgical strategy to promote early feeding. I think sometimes strategy at the first operation is to be able to provide a pathway forward that allows early enteral feeding. And it's often times sometimes better to stage the idea that you're going to put this back in continuity under more control. So what do the experts suggest to avoid or congate huge intestinal losses. In a situation of overwhelming intestinal loss like here, um the strategy for us is to um provide a control proximally that allows feeding to occur without the enteric stream growing and to actually leave a lot of questionable bowel later with the experience that many of that, many segments of bowel that are deemed to be non-usable actually in this population has a potential to heal and can really make a huge difference in the lifetime of this child. So as long as you can divert proximal and the baby is stable, you can leave questionable bowel for potential at later secondary reconstructive procedures. So plan your surgery ahead, taking consideration what the patients need. Do they need a T2? Do they need a train? Do they need a proximal diversion? Do we need to leave questionable bowels for a second look? Planning is key for this patients. So think before acting. Four. The best way to feed the baby is enterly with the appropriate nutrition according to the age. You have to properly manage lipids and proteins for achieving a healthy growth. The overarching principle is we wanted we want to deliver adequate nutrition to to have normal growth within normal parameters. Ideally that's enteral. But uh, you know, as these kids are adapting, uh, they're going to be either partially or totally parentally dependent for at least some period of time. The other guiding principle is as much as possible, we'd like to try to establish normal feeding behavior. Realizing that enteral nutrition is more than just nutrition. Perfect. So the guiding principles to start feeding are achieving healthy growth and trying to establish normal feeding behavior. Now, what about well patients that needs the tube for feeding? If a patient needed to be tube supported from the beginning, I would typically try to do that with bolus feeding, uh, rather than default to continuous feeding. Sometimes when they've had, uh, you know, a septic event or they're premature or an insult, there's there's motility issues, delayed gastric emptying, um, and they just don't tolerate food into the stomach. And often, you know, our strategy here would be if if the child failed a gastric approach, bolus and then continuous, then we would consider feeding beyond the stomach and decompressing the stomach, uh, through an NG. Great. So start with stomach feeding, but if it fails, feed beyond the stomach and decompress it to promote its motility. And what about which formula should we use? Obviously, formula of choice coming from the breast, breast milk. Always best. Breast milk. Yes. Breast milk, not only for its nutritional, uh, benefits obviously, but, uh, all the other goodies that are within the breast milk. Okay. So no doubt breast milk from a mom or a doubt. But if we don't have breast milk, what is the best formula? There is a myriad of formulas out there, but the the principles are, you know, we have intact formulas and we have either semi-elemental or elemental formulas. And you, two modules I think that are important to talk about are the protein module and the fat module. So let's talk about the protein module first. Starting at the the bare bones, you know, single amino acid will is going to be, you know, our generalized preference in making sure they're not having high stool output, high fluid losses, wound breakdown, rashes, um, emesis are all the limiting factors. Regarding the protein level, we have to know that single amino acid level is good from an allergy point of view, not absorption. But what about fat? There's this feeling out there that especially in the setting of short bowel syndrome that an MCT fat is better tolerated, better absorbed. But I would argue that uh long chain fat is the preferred module rather than MCT. Long chain fat is a much stronger stimulus for GLP2 release and that's what we want when we're trying to drive adaptation. Awesome. So we use long chain fat instead of middle chain fat or MCT to drive adaptation and stimulate the secretion of GLP2. Fifth, parental nutrition plays a huge role in getting this patients to achieve healthy growth. So managing its volume and components are crucial for this. So let's talk about um TPN. Should every kid be on Smuf? Of course. Smuf lipid means soy bean, medium tan triglyceride, olive oil, and fish oil. No, I don't think that's absolutely necessary. Um, for pre-term babies, Smuf is not the ideal lipid emulsion, but it's kind of the best we have. There is some ongoing research and development into newer lipid emulsions. Um, the the deficit with with Smuf is that it doesn't have enough arachidonic acid in it. Um and arachidonic acid is really important for brain development. Okay, so lipid emulsions with Smuf are not always the best option. So, we have two strategies to treat cholestasis. The first one is to reduce the total amount of fat. And the second one is to change the composition to introduce Smuf lipids or Omegaven. Those restriction essentially reduce lipid dose to 1 gram per kilo per day and can reverse cholestasis, but results in reduced calorie delivery that can impair growth and potentially impact neurocognitive development. Changing composition usually means using alternative lipid with added omega-3 fatty acids. That can be either Omegaven, which is essentially pure fish oil with omega-3 and is dose at 1 gram kilo, so babies take a calorie hit, or Smuf lipids, which is the better choice as it is more well balanced emulsion with an omega-3 and omega-6 ratio of 2.5 to 1, being less inflammatory that intralipid and promoting bioflow. And remember, you should not restrict Smuf lipids, so they can't be given at less than two or 2.1 grams per kilo per day. So now it's time to summarize. Infants and young children have a great potential for gut growth, with the bowel increasing length in the first few years of life. Preservation of the distal ileum and proximal colon is more critical than solely focusing on the ileocecal valve. Planning surgeries with controlling on proximal fecal flow, diverting if necessary, and leaving questionable bowel can promote long-term enteral autonomy. Breast milk is the preferred option for this patients. But if unavailable, selecting a formula that manages protein and fat intakes is key. Parental nutrition plays a vital role in achieving healthy growth. While Smuf is commonly used, there's ongoing research of new lipid emulsions. Thank you for watching this top key takeaways from the First Intestinal Rehabilitation Web. Don't forget to subscribe to the Stay current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Global Cast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.